Part 59

The pain experienced in swallowing is often manifested by convulsive action of the muscles of deglutition and of the muscles of the face. The swollen tonsils prevent the soft palate from being applied to the surface of the pharynx, as usual in deglutition; and as the upper or retro-nasal portion of the pharynx thus fails to be shut off from the lower oesophageal portion, liquids are often forced up into the nasal passages posteriorly, and are regurgitated through the nostrils, thus rendering it impracticable, for the time, to slake thirst or to swallow liquid nourishment.

At first sensations of dryness and pastiness in the throat are complained of, but in a few hours these symptoms become relieved by a more copious secretion of mucus or mucus and saliva. This secretion soon becomes viscid, and so adherent to the parts as to be detached only with difficulty, thus causing harassing efforts for its dislodgment by hawking and expectoration, or equally distressing efforts to swallow it. Should the inflammatory process extend to the salivary glands, as is not infrequently the case, secondary ptyalism often results, with increased distress from this source, and the patient lies or sits with his head inclined upon the diseased or most diseased side to favor the uninterrupted flow of saliva from the mouth.

Extension of the inflammatory process to the submaxillary glands, or to the parotid, or to the connective tissue surrounding them, is indicated by tumefaction externally, which is often exquisitively sensitive to pressure.

The timbre or quality of the voice is often impaired in a peculiar manner by the tumefaction of the throat and the immobility of the soft palate. The voice is thick, throaty, or guttural, having a characteristic harsh, rasping aspiration in enunciation, while articulation is much impeded by impairment in the movements of the jaw, palate, tongue, and lips. At times it is also painful. Speech is sometimes indistinguishable or impossible, and the voice may even become suppressed, so that signs and writing remain the sole means of communication.

Impairment of respiration, at least to any considerable degree, does not occur, unless both tonsils are involved and swollen to an intense degree--conditions under which dyspnoea may become pronounced, severe, and even urgent, and suffocation become imminent. Painful respiration is not uncommon in rheumatic tonsillitis.

The fever is sthenic in type. There are often severe aching pains in {383} the limbs. Headache, restlessness, insomnia, nausea, and even vomiting, may occur. The tongue is heavily coated, the breath is fetid, appetite is impaired, and the bowels are constipated. The urine is diminished in quantity, high-colored, and of high specific gravity. It usually shows slight increase of urea and great diminution of chlorides. Albuminuria occurs in rare instances.

The symptoms are proportionate to the severity of the attack. A first attack is usually much severer than subsequent ones, and suppurative cases more severe than those terminating by resolution. Resolution is the usual termination, and the parts are restored to a normal condition at the end of ten to fourteen days, sometimes earlier; in exceptional cases not until three or four weeks. Sometimes permanent hypertrophy of the tonsil remains.

Where the inflammatory process fails to subside, suddenly at the end of five or six days, or a little later, or not until ten days to a fortnight have passed, slight rigors supervene, announcing suppuration, and the local distress is very great, with pulsation and lancinating pains in the tonsils, until all at once the abscess bursts and its contents are discharged with immediate relief. Sometimes the pus or much of it is involuntarily swallowed; sometimes it is expectorated. In exceptional instances the pus has escaped into the larynx and suffocated the patient, usually during sleep. In rare instances the abscess, having burrowed beneath the pharyngeal muscles, may open at the external angle of the jaw or behind the sterno-mastoid muscle. It may discharge into the epiglotto-pharyngeal fold, and thence reach and distend the epiglottis. It has been known to descend along the planes of connective tissue into the mediastinum or into the lungs. Even ulceration into the maxillary and carotid arteries has occurred, usually with fatal result, occasionally with an opportunity to save life by ligating the carotid (Erhmann).

The most frequent point of spontaneous rupture externally is at the upper portion of the gland anteriorly, just beneath the anterior palatine fold. Sometimes internal rupture occurs into the lacunæ.

Termination by gangrene is exceptional, and is confined to individuals with debilitated constitutions. It is much less frequent than formerly--as a result, perhaps, of better methods of treatment.

Metastasis is one of the methods of termination as to joints or muscles in rheumatic tonsillitis--to lungs, brain, or gastro-intestinal tract--as formerly occurred with much more frequency under direct depletory treatment.

In rare cases extension of the inflammation occurs to the epiglottis, even to the larynx, and the laryngitis may be so severe as to threaten life from the occurrence of oedema. Diffuse inflammation of the retro-pharyngeal connective tissue or of the connective tissue of the neck may constitute an unpleasant complication of the disease.

In a few instances paralysis of the palate occurs as a sequel of tonsillitis, and in exceptional cases the paralysis may also affect the arytenoid muscles of the larynx, and even the accommodator muscles of the eyes.

PATHOLOGY AND MORBID ANATOMY.--Tonsillitis is almost always {384} associated with inflammation of the tissues surrounding the tonsil and those contiguous to it, even in the mildest and most frequent manifestations of the affection. Thus, inflammation of the palate (staphyllitis) and uvula, and even of the pharynx (pharyngitis), are anatomically included with tonsillitis in angina or sore throat.

The mildest form of the malady is a catarrhal inflammation of the mucous membrane covering the gland, and does not extend along the lacunæ which dip inward from the surface and divaricate toward the interior of the organ. It is termed catarrhal tonsillitis, and, as has been intimated, is almost always associated with catarrhal sore throat. It is attributed to hyperæmia, with passive engorgement of the vessels, following retrocession of blood from the cutaneous surface after undue exposure to cold and moisture. A severer form of the malady involves the lacunæ in addition--several or all of them. This should be termed lacunar tonsillitis, as suggested by Wagner. Primarily, at least, it does not involve the follicles of the tonsils which open into the lacunæ, and is therefore incorrectly denominated follicular tonsillitis, although it is most generally so described. The lacunæ are involutions of the mucous membrane, and in health furnish a slightly turbid mucoid secretion which serves to lubricate the parts and, as is generally believed, to facilitate deglutition. When the lacunæ are inflamed these products become pent up in them to a certain extent, accumulate, and project in part at their orifices in turbid creamy or curdy masses, plastered over the parts when thin in consistence, or tightly imbedded when thick or desiccated. These masses are usually white, but sometimes, owing to various admixtures, they are more or less yellowish or gray or brown. They consist of epithelium chiefly, with more or less pus and accumulation of cells similar to those of which the follicles are composed--whether from follicles which have become distended by proliferation of their constituents, and have then burst, is not known. This epithelium has often undergone fatty degeneration in part. Cholesterin is an occasional constituent, and swarms of micrococci and bacteria abound when the masses are not recent, especially if the inflammation is occurring in a tonsil long the seat of chronic disease of the lacunæ.

The tonsil itself is moderately swollen and its mucous membrane hyperæmic. If the parenchyma of the tonsil be involved likewise, as often occurs, the swelling will be much greater, so that the gland will project a considerable distance beyond the margins of the palatine folds. When a hypertrophied tonsil is the seat of the inflammation the tumefaction will be much greater than when the inflamed tonsil has been normal.

Acute inflammation of the palatine folds often coexists, especially of the anterior fold. The soft palate may also be engaged in the morbid process, which may involve the uvula likewise. Pharyngitis is an occasional accompaniment, and stomatitis quite a rare one.

Lacunar tonsillitis sometimes subsides by spontaneous evacuation of the pent-up contents of secretion and desquamation, the parts returning to their normal condition. More frequently a desiccation of some of these products ensues, with permanent chronic inflammation. Decomposition then often takes place, fouling the breath by the escape of the gases. Butyric acid has been recognized as one of the most prominent of these fetid {385} gases. Calcareous change occurs in these contents of the lacunæ in some instances. Lacunar or follicular tonsillitis is often associated with severe inflammation of the peritonsillar connective tissue and the contiguous palatine fold, with serous or cellular infiltration into these structures almost always terminating in suppuration. This form of tonsillitis is very frequent, and is often confounded with parenchymatous tonsillitis or with tonsillar abscess. In these cases the abscess is in the peritonsillar tissue or in the posterior leaflet of the anterior palatine fold. It bursts above the tonsil at the angle between the two folds in the greater number of cases. In some instances the suppurative inflammation affects the anterior surface of the posterior palatine fold, sometimes contiguously to the antero-tonsillar abscess, sometimes independently, constituting a retro-tonsillar abscess. The follicles in the posterior palatine fold are sometimes involved, the thickened anterior surface of this structure becoming studded with small projections the size of ordinary pinheads or larger, distended with whitish-yellow contents.

In another class of cases of tonsillitis the inflammatory process may be chiefly parenchymatous, for rarely is it wholly so. That is to say, it may involve the glandular structure of the organ wholly or in main part. The disease is then an adenitis, an inflammation of gland-tissue--tonsillitis per se. It is associated with superficial inflammation of the surrounding mucous membrane, secondarily if not primarily, and often with inflammation of the lacunæ. In many instances the parenchymatous inflammation is a direct extension of the lacunar inflammation.

Parenchymatous tonsillitis may subside by resolution, or, as is quite frequent, terminate by suppuration. A number of small abscesses may be formed, which usually become confluent and rarely remain discrete. Sometimes a single large abscess is formed. The confluent abscess may discharge by several points. It is always associated with a severe inflammation of the palatine folds and palate, especially the anterior fold; sometimes of the adjoining half of the soft palate and the uvula; sometimes of the entire velum and uvula. Sometimes these parts become oedematous; sometimes suppuration ensues. Severe pharyngitis is not uncommon. Glossitis, involving the posterior portion of the tongue especially or exclusively, is an occasional accompaniment of parenchymatous tonsillitis. (See GLOSSITIS.) Occasionally oedema takes place in the epiglottis and upper margin of the larynx.

The character of the secretions varies. Sometimes these are semifluid; sometimes soft, caseous, or pultaceous; sometimes fibrinous and arranged in pseudo-membranes; sometimes hemorrhagic; sometimes moist and viscid, sometimes very dry; often adherent, and always containing cryptogams (leptothrix, Oïdium albicans, bacteria, and micrococci). Collections of caseous products accumulate not only in the crypts of the tonsils and in their overlying mucous membrane, but likewise in the follicles of the palatine folds below the tonsil, and thence toward the base of the tongue.

The submaxillary glands often undergo engorgement, and become so tender that external manipulation is painful, and sometimes they undergo suppuration. The tumefaction due to the swollen glands and infiltrated connective tissue around it is frequently incorrectly referred to the tonsil itself, rather than to the accompanying inflamed palate, with the {386} lymphatics of which these glands are in more direct anatomical connection. The tonsil is at a considerable distance from the inflamed glands, and cannot be felt from the exterior except under unusual circumstances.

Herpetic tonsillitis is a rare form of inflammation of the tonsil, or rather of its investing mucous membrane, characterized by the eruption of herpetic vesicles on its surface. The vesicles soon undergo rupture, and the resulting ulcers coalesce and become covered with a fibrinous exudation. The disease is usually associated with similar vesicles upon the palatine folds and upon the soft palate, and exceptionally with vesicles on the pharynx. (See Herpetic Pharyngitis.) It is by some fortuitous circumstance only that it is observed in the vesicular stage. It is confined to one side of the throat in most instances, but may be bilateral also.

Mycosis tonsillaris has been described by a few observers. B. Fraenkel has recorded three cases, E. Fraenkel one, and Bayer two. In these cases the disease was not confined to the tonsils, but implicated the calciform papillæ of the tongue also, and one of Bayer's cases some pharyngeal follicles in addition. E. Fraenkel's case was in a male, and occupied but the right tonsil and base of tongue. The white masses in this case were formed of spores and filaments (Bacillus fasciculatus, Sadebeck), which are described as penetrating some millimeters into the gland-tissue. These masses were tenacious, and were reproduced rapidly after removal. In Bayer's cases, both females, the same microphyte was recognized. In a female patient observed at the Philadelphia Polyclinic this affection followed rheumatic tonsillitis, diphtheria being prevalent near her residence, which was in a very unsalubrious locality. The deposit, confined to the left tonsil, was so firmly adherent to the mucous membrane that the implicated portion had to be torn away to get rid of the growth, which was twice reproduced. The fungus was in its mycelial state, a few spores and conidiferous filaments being recognized microscopically.

Quite recently, and since the above was written, the results of an elaborate study of this affection by Theodor Hering of Warsaw have been published in a paper entitled "Pharynxmycosis leptothricia," read before the Society of German Naturalists and Physicians. The author collates fourteen cases, six of which were observed by himself. He claims that the microphyte is simply the Leptothrix buccalis.

The local subjective symptoms as collated by Hering vary from the merest sense of discomfort in chronic cases to intense pain, difficulty in speech and in deglutition, and various grades of cough in acute ones. In some cases they are altogether wanting. Constitutional disturbance may be entirely absent or may be presented in various febrile or sub-febrile manifestations.

DIAGNOSIS.--The history of the attack, the appearances described, and the symptoms narrated should ordinarily suffice for a correct diagnosis. Still, mistakes do occur. An unsuspected tumor of the tonsil observed for the first time during an ordinary sore throat might be taken for an inflamed tonsil, but the progress of the case would soon lead to its due {387} recognition. While tonsillitis is infrequent after the fourth decennium, it occasionally occurs late in life, and has been observed even in the ninth decennium; and reserve is proper as to the cause of enlarged tonsils in the sore throats of those advanced in life.

The deposit in follicular or lacunar tonsillitis or angina is pulpy and not membraniform. It can be wiped from the surface with a fragment of sponge, and does not tear from the surface in strips, as is the case with the pseudo-membrane of diphtheria or of common membranous sore throat. There is no abrasion of the mucous membrane beneath the deposit. The patches are more prominent, usually more circumscribed, and dip down into the lacunæ, or rather project from the crypts upon the surface of the tonsil. In its physical aspect the deposit more closely resembles that observed in the sore throats accompanying cachectic conditions, as in chronic tuberculosis, advanced syphilis, some forms of scarlatina, typhus and typhoid fever, extreme old age (agine pultacée, Fr.; cachectic angina); but the existence of previous constitutional disease and actual debility should prevent the mistake in diagnosis. In susceptible subjects the oncoming of an attack of rheumatic tonsillitis may often be inferred, previous to the manifestation of local symptoms, from the existence of otherwise inexplicable odynphagia, the pain being especially intense upon attempts to swallow saliva. Sometimes laryngoscopic inspection at this early stage of the disease will reveal vivid redness of the mucous membrane in the neighborhood of the crico-arytenoid articulations. The value of this early diagnosis lies in the opportunity it affords to try abortive treatment.